Case Study: An Abandoned Patient High in the Alpine

The Setting

You are on a Search and Rescue (SAR) team whose members are Wilderness First Responders (WFRs). You and your team members hike on a rugged trail into Wyoming’s Wind River Range, responding to a vague report that came in at midnight of a “very sick person” camped “near the trail near tree line.” Your team’s role is to sweep the trail in the dark in the hopes of finding out exactly what is going on. A second SAR group is gathering to hike up the trail later in support.

After a strenuous 8 mile uphill hike, as the first light of dawn is reaching this basin, you find a poorly pitched tent just off the trail at 11,300 feet. You call out, “Hello, is anyone in the tent? This is search and rescue. We have a report of someone who needs assistance.”

Silence in response and a distinct smell of vomit prompt you to look inside the tent.

You see a person curled in a sleeping bag, appearing pale and sickly. They open their eyes when you ask, “Hello, can I help?” They seem confused, but give you consent to help and tell you their name.

SOAP Report

Subjective

The patient is a 52-year-old female who is lethargic with altered mental status. She apparently hiked to the present location yesterday afternoon and was too ill and fatigued to continue. Her companions continued to a lake further up the trail with a vague plan to return if she did not arrive at their planned destination.

Objective

The patient denies any recent trauma. Head-to-toe exam findings are negative other than some minor scrapes and bruises on her lower legs. Listening with a stethoscope, her lungs are clear bilaterally. She can stand with assistance and walk slowly and wobbly.

VITAL SIGNS

Time

5:00 a.m.

Level of Responsiveness (LOR)

A+Ox2

Heart Rate (HR)

90, strong, regular

Respiratory Rate (RR)

22, regular, easy

Skin Color, Temperature, Moisture (SCTM)

Pale, warm, dry

Blood Pressure (BP)

150/94

Pupils

Equal, round, reactive to light

Temperature (T°)

99°F (37.2°C) oral

Blood Sugar

“High” reading on glucometer

HISTORY

Symptoms:

Weakness, lethargy, nausea. She denies headache, shortness of breath, chest pain, abdominal pain, or painful urination. She is not consistently oriented to place and time and requires multiple questions to elicit her medical history and recent events.

Allergies:

Denies.

Medications:

Multiple medications prescribed to the patient are discovered in her tent: simvastatin (for cholesterol), captopril (for blood pressure), and insulin. The last time the patient took any of these medications is unknown. She states she needs to take insulin and try to eat.

Pertinent Hx:

This is unclear and unreliable. Patient does report a history of diabetes and a recent urinary tract infection.

Last in/out:

Patient says she has been drinking water; however, there is no water source near the tent and all of her water bottles are empty. It appears she has vomited several times. Patient denies diarrhea and there is no evidence of diarrhea. She urinated dark smelly urine once since the SAR team arrived.

Events:

Rescuers think the patient lives at sea level and hiked 8 miles, gaining 3000 ft. of elevation, to this location yesterday. She became fatigued and decided to stop for the night. Her companions continued on.

STOP READING!

What is your assessment and plan? Take a few minutes to figure out your own assessment and make a plan. Don’t cheat—no reading on without answering this first!

Assessment

Plan

Use the second SAR team to move the patient to a helicopter landing zone

Monitor the patient, encourage her to drink water.

Anticipated Problems

Patient’s condition worsens.

Helicopter is unavailable and litter evacuation will be needed, which means requesting additional Advanced Life Support (ALS).

Note from NOLS on Existing Medical Conditions in the Backcountry

A wilderness rescue often calls to mind scenarios of sprained ankles or hypothermia—yet existing medical conditions are also a part of a patient's experience. People hike into the wilderness carrying their medical history along with their backpacks.

The rescuer's role is to perform a thorough patient assessment (PAS), identify immediate life threats (there are none present in this scenario), identify pertinent medical interventions and treatments (in this, case oral fluids only), and determine the need for and urgency of evacuation (which needs to be done promptly due to the apparent hyperglycemia and the patient’s altered mental status).

This patient has multiple ongoing medical conditions that a Wilderness First Responder can identify, but for which there are no interventions in their scope of practice, other than monitoring the patient’s condition, administering oral fluids, and initiating an evacuation.

The Tale Continues...

The apparent hyperglycemia appears to be the most urgent problem. Since you are unsure if the patient can make a good decision about her insulin dose, you ask her to wait until she sees doctor. The patient agrees.

Altitude illness is also on your problem list. The patient’s lungs are clear and there is no respiratory distress (unfortunately, no pulse oximeter is available). You think about asking the patient to try a heel-to-toe walking test, which might suggest high altitude cerebral edema (HACE). But because the patient is unsteady, it would be unclear as to whether the results of the test indicate HACE or a different underlying medical problem.

The End of the Tale

When the second SAR team arrives the patient is packaged in a litter and carried a few hundred yards to a suitable landing zone for the evacuation helicopter. Luck is on your side and the helicopter arrives promptly.

At the hospital, it is found that the patient indeed was hyperglycemic and had a history of cardiovascular disease. She spends several days in the hospital. Her companions hike out the day after the evacuation and report her missing. (You think this patient needs different companions who won’t leave her behind when she’s sick. But giving her that advice is not in the Wilderness First Responder scope of practice.)

As a NOLS Instructor since 1973 and a WEMT, volunteer EMT on ambulance and search and rescue squads since the 70s, Tod Schimelpfenig has extensive experience with wilderness risk management. He has used this valuable experience to conduct safety reviews as well as serve as the NOLS Risk Management Director for eight years, the NOLS Rocky Mountain Director for six years, and three years on the board of directors of the Wilderness Medical Society, where he received the WMS Warren Bowman Award for lifetime contribution to the field of wilderness medicine. Tod is the founder of the Wilderness Risk Manager’s Committee, has spoken at numerous conferences on pre-hospital and wilderness medicine, including the Australian National Conference on Risk Management in Outdoor Recreation, and has taught wilderness medicine around the world. He has written numerous articles on educational program, risk management and wilderness medicine topics, and currently reviews articles for the Journal of Wilderness and Environmental Medicine. Additionally, he is the author of NOLS Wilderness Medicine and co-author of Risk Management for Outdoor Leaders, as well as multiple articles regarding wilderness medicine. Tod is currently the Curriculum Director of NOLS Wilderness Medicine.